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.� SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # 9-5-142— <br /> (Circle <br /> 9-5—142—(Circle One) <br /> B. SOURCE OF INFORMATI , <br /> Name: re , Phone: <br /> Company: 3 <br /> Address: <br /> Designated Employee Name: cz Phone:bk.�q)Y,�e-3 Y&J? <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE-��-. <br /> Location: S! `i /d r--1, Cam.& <br /> (Best Physical Descriodon) v -(mor County) Circle One <br /> Date of Discharge: <br /> Date Notified: 5C 1 7— Y 3 Time-- ) <br /> V <br /> D. RESPONSIBLE PERSON/BUSIIIESS <br /> Name of Business: R 1V ✓l1 1 ss / — <br /> Contact Person: i L n i me kp 1 \1 E L4 Telephone: _11-cD <br /> Physical Address ,5 1 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: S,Q <br /> Volume: OYLs <br /> Chemicals: <br /> Circumstances: S <br /> F. ACTION TAKEN <br /> � P <br /> SITE DISPOSITION <br /> C. <br /> f <br /> EH 22 013 (Rev.4/91) <br />